ABSTRACT
We present a rare case report of a patient diagnosed with primary plasma cell leukemia (PCL) who presented with atypical signs and symptoms which acutely evolved into life-threatening multi-organ failure. This case raises questions regarding the latest diagnostic guidelines and therapeutic options in the management of acute PCL and reinforces the need for prompt treatment after diagnosis.
ABSTRACT
We present a case of a 34-year-old right-handed Caucasian male with chronic occipital neuralgia refractory to medical therapies and minimally invasive pain procedures who underwent surgical cervical dorsal root ganglionectomy which completely relieved his headaches. The histopathological and immunohistochemical findings of the resected cervical dorsal root ganglia were consistent with active herpes simplex virus type 1 (HSV-1) infection causing ganglionitis. To the best of our knowledge, this case represents the first histopathologically proven HSV-1 cervical dorsal root ganglionitis in humans. This case provides an insight into a possible etiology of occipital neuralgia.
ABSTRACT
PURPOSE: Electronic health records (EHRs) present an opportunity to access large stores of data for research, but mapping raw EHR data to clinical phenotypes is complex. We propose adding patient-reported data to the EHR to improve phenotyping performance and describe a retrospective cohort study demonstrating a test case in depressive disorder. METHODS: We compared four EHR-phenotyping methods based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, medication records, and the Patient Health Questionnaire 9 (PHQ-9) regarding the ability to identify cases with depression and characteristics of patients identified with depression. Our sample included 168,884 patients seen (2007-2013) at our neurological institute. We assessed the diagnostic performance in a subset of 225 patients who had a reference standard measurement available. RESULTS: ICD-9-CM codes identified the fewest number of patients as depressed (4,658), followed by PHQ-9 (46,565), and medication data (50,505). The presence of at least one of these criteria identified the largest number (78,322). The PHQ-9 identified a higher proportion of elderly, disabled, Medicaid, and rural patients, as compared to ICD-9-CM codes. ICD-9-CM codes were least sensitive (6.7% sensitivity), whereas the method using at least one of the criteria identified the highest number of truly depressed patients (93.3% sensitivity); however, specificity dropped from 97.7 to 58.1%. CONCLUSIONS: The choice of phenotyping method may disproportionately exclude patient groups from research. Patient-reported data hold potential to improve sensitivity while maintaining an acceptable loss of specificity, depending on the context. Researchers should consider including patient-reported data in EHR-driven phenotyping methods.
Subject(s)
Electronic Health Records , Patient Outcome Assessment , Surveys and Questionnaires , Aged , Depressive Disorder/therapy , Female , Humans , International Classification of Diseases , Male , Middle Aged , ROC Curve , Retrospective Studies , Sensitivity and Specificity , United StatesABSTRACT
OBJECTIVE: This study aimed to assess the accuracy and operating characteristics of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adults with epilepsy. METHODS: Tertiary epilepsy center patients served as the study population, with 237 agreeing to structured interview using the Mini-International Neuropsychiatric Interview (MINI), a "gold standard" instrument developed for rapid diagnosis of neuropsychiatric disorders, including major depressive disorder (MDD); 172 also completed the PHQ-9, and 127 completed both the PHQ-9 and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) within two days of the MINI. Sensitivity, specificity, positive and negative predictive values, and areas under the ROC curves for each instrument were determined. Cut-points of 10 for the PHQ-9 and 15 for the NDDI-E were used, and ratings at or above the cut-points were considered screen-positive. The PHQ-9 was divided into cognitive/affective (PHQ-9/CA) and somatic (PHQ-9/S) subscales to determine comparative depression screening accuracy. RESULTS: The calculated areas under the ROC curves for the PHQ-9 (n=172) and the PHQ-9/CA and PHQ-9/S subscales were 0.914, 0.924, and 0.846, respectively, with the PHQ-9 more accurate than the PHQ-9/S (p=0.002) but not different from the PHQ-9/CA (p=0.378). At cut-points of 10 and 15, respectively, the PHQ-9 had higher sensitivity (0.92 vs 0.87) but lower specificity (0.74 vs 0.89) compared with the NDDI-E. The areas under the ROC curves of the PHQ-9 and the NDDI-E showed similar accuracy (n=127; 0.930 vs 0.934; p=0.864). SIGNIFICANCE: The PHQ-9 is an efficient and nonproprietary depression screening instrument with excellent accuracy validated for use in adult patients with epilepsy as well as multiple other medical populations.
